A Human Factors Approach to Accident Analysis and Prevention
About the Workshop
Attendees will learn how to apply an innovative methodology for conducting a comprehensive,
human factors analysis of accidents and injuries associated with human error. The approach is
grounded in the Human Factors Analysis and Classification System (HFACS), originally
developed by researchers to facilitate the analysis of human errors associated with aviation
accidents. HFACS is based upon Reason’s “Swiss Cheese” model of accident causation, which
conceptualizes human error as the product of complex interactions among myriad latent and
active system variables. HFACS translates Reason’s theory into practice via a pragmatic
framework that systematically guides the analysis of human factors data associated with errors
that cause adverse events. Since it original development for aviation, HFACS has been
successfully applied across a variety of high-risk industries and has undergone extensive usability
testing. Numerous studies have shown HFACS to be a comprehensive and reliable analysis tool
that can lead to effective corrective actions for reducing accidents. Recent research in healthcare
has also shown HFACS to be a feasible and effective tool for analyzing human factors associated
with patient harm events.
Learning Objectives: Attendees of this intensive, two-day workshop will learn to apply new
techniques to help their organization: (1) identify the causes of errors that lead to adverse events
and (2) develop preventative measures to lower risk and improve performance. Specifically,
attendees will learn how to:
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Integrate human factors and system safety concepts into root cause analysis (RCA) and
other investigation processes,
Utilize the Human Factors Analysis & Classification System (HFACS) to identify
systemic causes of human error during an investigation,
Conduct structured, human factors interviews using HFACS
Transform traditional analytical tools like the fishbone diagram, fault trees, and link
analysis using HFACS,
Implement the Human Factors Intervention Matrix (HFIX) to develop innovative
corrective action programs, and
Develop a human error database and tracking system for monitoring and evaluating
performance improvement efforts.
Preliminary Agenda
HFACS Workshop Day 1
08:00-08:30
Introductions
08:30-09:15
System Safety and RCA
09:15-09:30
Break
09:30-10:30
HFACS (unsafe acts)
10:30-10:45
Break
10:45-12:00
HFACS (preconditions to unsafe acts)
12:00-13:00
Lunch
13:00-14:30
HFACS (supervisory and organizational factors)
14:30-14:45
Break
14:45-16:00
HFACS Activity
HFACS Workshop Day 2
08:00-09:00
HFACS Review
09:00-10:00
HFACS Interviewing
10:00-10:15
Break
10:15-12:00
HFACS Case Study
12:00-13:00
Lunch
13:00-13:50
HFACS Case Study Review
13:50-14:00
Break
14:00-14:50
HFIX/FACES
14:50-15:00
Break
15:00-15:45
HFIX/FACES Activity
15:45-16:00
Wrap-up
About the Speakers
Dr. Wiegmann is an Associate Professor of Industrial and
Systems Engineering at the University of Wisconsin-Madison.
Before joining the faculty at UW-Madison, Dr. Wiegmann was the
Director of Human Factors and Patient Safety Research within the
Division of Cardiovascular Surgery at the Mayo Clinic. He also
formerly served as an aviation psychologist and accident
investigator for both the National Transportation Safety Board and
the United States Navy. Dr. Wiegmann received his B.S. in
psychology from the University of Wisconsin-LaCrosse (1988) and
his M.Sc. (1990) and Ph.D. (1992) in cognitive psychology from
Texas Christian University. He also holds a postdoctoral master’s
degree in biomedical science from the Mayo Clinic College of
Medicine (2007). Dr. Wiegmann has published extensively on the topics of human factors and
safety and has received multiple awards for his work in both aviation and healthcare.
Dr. Shappell is currently a Professor and Chair of the Department of
Human Factors and Systems at Embry-Riddle Aeronautical
University. Before joining the faculty at ERAU in the fall of 2012, Dr.
Shappell was professor of Industrial Engineering at Clemson
University from 2005-2012. Before that, he was the Human Factors
Research Branch Manager at the Civil Aerospace Medical Institute. In
addition, he has served over 16 years in the U.S. Navy as an
Aerospace Experimental Psychologist. He has published/presented
well over 200 papers, books, and presentations in the fields of
accident investigation, system safety, spatial disorientation, sustained
operations and fatigue. Dr. Shappell received a B.S. in psychology
(1983) from Wright State University graduating Summa Cum Laude
with honors in psychology and a Ph.D. in Neuroscience from the
University of Texas Medical Branch in 1990.